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2. 

   Bike San Joaquin Lending Application
   

   Please fill out the following fields to apply for the Bike San Joaquin long term lending program. Failure to complete the required information may result in disqualification from the Bike San Joaquin program. If approved, the Bike San Joaquin team will reach out for more information. Please allow up to two weeks for processing. Please also note that e-bikes must be stored securely and user must have access to a wall plug for charging.

4. First Name*
5. Last Name*
7. Home Address*
9. City*
10. State*
11. Zip Code*
13. Email Address*
14. Phone (XXX-XXX-XXXX)*
16. Birthdate (MM/DD/YYYY)*
17. Age in Years*
19. Race/Ethnicity
    -- Select One --WhiteAfrican AmericanNative American/Alaskan NativeHispanic or LatinoAsianPacific Islander
20. Gender
    -- Select One --MaleFemale
22. How many people live in your household? If you are supported by a parent or guardian, include the number of people living in that household.*
24. What is your annual household income? If you are supported by a parent or guardian, include that total household income.*
28. Communication Acknowledgement

    I agree to receive email and/or telephone communication related to Bike Stockton program from SJCOG and its project partners.

30. Type "Yes" to acknowledge*
31. Preference (select at least one)*

    1. Email

    1. Phone

    1. Text
35. Attestation

    I certify that I have read the Bike San Joaquin Lending Agreement, and that the information provided in this application form is correct to the best of my knowledge. I understand that, if I am not qualified for the equity pricing, I will be required to pay a $149 refundable deposit to receive the e-bike.

37. Type "Yes" to acknowledge*

41. Eligibility and availability of bikes is subject to approval and funding availability. SJCOG reserves the right to request proof of eligibility to confirm a participant’s age and home address.

43. Signature (type your name in the field to sign)*
44. Date*
    Date
48. E-Bike Delivery Information

    If approved, when would you like to receive your e-bike?

50. Preferred weekday:
51. Preferred time:

    1. AM

    1. PM
53. Where will the bike be stored?
55. At the time of delivery, please have the following items:
    • Smart phone with Bluetooth capability and Bike San Joaquin app.
    • Receiver must be applicant with identification matching this form (e.g., photo ID and/or utility bill).
    • Delivery to applicant address only. Will not enter residence.
    • Scheduling via e-mail/phone may exceed two weeks due to staff availability.
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field